Case Presentation:

A 93–year–old woman with advanced Alzheimer’s disease was admitted from her nursing care facility with abdominal pain. She was Spanish–speaking only and was profoundly hearing impaired. She was unable to provide any history or further details even with the help of a translator. Nursing staff at her facility reported that she had exhibited right upper quadrant abdominal pain beginning the prior evening before going to bed. She was brought to the emergency department when the pain persisted unabated. There was no report of nausea, vomiting, diarrhea, fevers or chills. Her appetite had been good recently and she was tolerating PO intake without impediment. There had been no recent weight loss, shortness of breath, chest pain, dysuria or rash. On initial presentation she was afebrile with normal vital signs. On exam she was an elderly woman, alert and arousable, but not oriented, as was her baseline. Her physical exam was otherwise normal. Her abdomen was soft and nontender with normoactive bowel sounds, and no rash was observed on her abdomen or chest wall. During her evaluation she was observed to periodically shriek in pain on turning in bed or when sitting upright. An investigative laboratory panel was normal, including normal white blood cell count, normal liver enzymes, amylase, lipase and urinalysis. Imaging evaluation included a normal CXR, acute abdominal series, RUQ US, HIDA scan, abdomen and pelvis CT and CT angiography of the abdomen. A TLS spine x–ray revealed moderate multilevel degenerative disc disease of the thoracic and lumbar spine. An MR of the lumbar spine and pelvis revealed a large expansile heterogenous intramedullary mass extending from T3 to T7 levels. This was thought most likely an ependymoma and less likely an astrocytoma. She was seen in consultation by neurosurgery and, given her advanced age, dementia and poor functional status and prognosis, no further intervention was recommended. She was discharged to hospice on Decadron 4 mg IV q6h and a dilaudid PCA and she expired shortly thereafter.

Discussion:

Abdominal pain due to a spinal tumor–mediated thoracolumbar radiculopathy is rare but has been described in both the pediatric and adult literature. It is more typically observed in patients with chronic, undiagnosed abdominal pain. Patients typically present with concomitant back pain and neurologic symptoms on or soon after presentation. In this patient’s case, however, the precise nature and location of her pain, much less any associated neurologic symptoms, were not ascertainable due to her advanced dementia and language barrier.

Conclusions:

Though exceedingly rare, spinal tumors can manifest with abdominal pain via a thoracolumbar radiculopathy. The presence of atypical clinical features and a negative gastroenterological evaluation may suggest this diagnosis and prompt judicious neuroaxis imaging in the appropriate clinical context.